16 ème Journée d'automne Lausanne, le 19 octobre 2017 Hépatopathies auto-immunes Nurullah Aslan et Darius Moradpour Service de Gastroentérologie et d'hépatologie Centre Hospitalier Universitaire Vaudois Université de Lausanne l Primary biliary cholangitis www.gastro-hepato.ch l Primary biliary cholangitis l Prevalence 15-25/100'000 l : = 3 : 1 l Clinical manifestations highly variable (asymptomatic - acute liver failure - chronic hepatitis - cirrhosis) l May be associated with other autoimmune diseases (AIH-PBC, AIH-PSC) AASLD Practice Guideline - Manns MP et al. Hepatology 2010;51:2193-2213. EASL Clinical Practice Guideline. J Hepatol 2015;63:971-1004. Diagnosis l Exclusion of other liver diseases l Autoantibodies ANA, SMA (anti-actin) anti-lkm1 Others: SLA/LP, anti-lc1 l γ-globulins (IgG) l Liver biopsy l Response to treatment Type 1 Type 2 Simplified Diagnostic Criteria 6 points! probable AIH (sens. 88%, spec. 97%) 7 points! definite AIH (sens. 81%, spec. 99%) Points Autoantibodies ANA or SMA 1:40 1 ANA or SMA 1:80 or LKM 1:40 2 or SLA/LP pos. (any titer) IgG (or γ-globulins) > ULN 1 > 1.1 x ULN 2 Liver histology Compatible with AIH 1 Typical of AIH 2 Absence of viral hep. Yes 2 Hennes EM et al. and the IAIHG. Hepatology 2008;48:169-176. 1
Treatment l Predniso(lo)ne 0.5-1 mg/kg/d! reduction to 10 mg/d by 10-12 wks and to 5 mg/d by 6 months! if possible, withdrawal by 1 year l Azathioprine 50 mg/d! 1-2 mg/kg/d l Goal: complete remission (ALT, IgG, histology) Courtesy of Prof. Christine Sempoux l Duration at least 3 years Treatment l Autoimmune hepatitis l Alternative treatment options - Budesonide (only in non-cirrhotic pts) - Intolerance to azathioprine: MMF - Insufficient response: i.v. corticosteroids, CsA, tacrolimus, infliximab,... l Primary biliary cholangitis l Primary sclerosing cholangitis l Overlap syndromes l Regular follow-up and treatment adherence are essential l IgG4-associated cholangitis l F.k.a. primary biliary cirrhosis l Autoimmune disease with progressive destruction of small bile ducts l Prevalence 2-40/100'000 l : = 9 : 1, peak age 40-60 years l May be associated with other autoimmune diseases (Sjögren's syndrome, thyroiditis, celiac disease, RA,...) AASLD Practice Guideline - Lindor K et al. Hepatology 2009;50:291-308. Beuers U et al. J Hepatol 2015;63:1285-1287. EASL Clinical Practice Guidelines. J Hepatol 2017;67:145-172. 2
Clinical Manifestations Diagnosis l Initially asymptomatic (AP, γ-gt ) l Alkaline phosphatase, γ-gt l Pruritus l Jaundice represents a late manifestation l Antimitochondrial antibodies (AMA) (anti-m2 = E2 subunit of pyruvate dehydrogenase complex) Sensitivity and specificity > 95% l Xanthomas, osteopenia / osteoporosis,... l IgM l Complications of cirrhosis l Liver biopsy (not mandatory) l Fatigue Histological Stages Ludwig's classification. Lindor KD and Levy C. In: Zakim and Boyer's Hepatology. 6th ed. Elsevier 2012. Management l Ursodeoxycholic acid 13-15 mg/kg/d l Autoimmune hepatitis l Second line: obeticholic acid 5! 10 mg/d l Primary biliary cholangitis l Treatment of pruritus (cholestyramine, rifampicin, naltrexone, sertraline, phototherapy,...) l Primary sclerosing cholangitis l Prevention / therapy of osteoporosis l Liver transplantation l Overlap syndromes l IgG4-associated cholangitis l Investigational: fibrates,... 3
Primary Sclerosing Cholangitis l Chronic fibrosing inflammatory process of medium- and/or large-size, intra- and/ or extrahepatic bile ducts l Prevalence 5-10/100'000 l : = 2 : 1, median age at diagn. 40 yrs l 80% associated with IBD (UC > CD) EASL Clinical Practice Guideline. J Hepatol 2009;51:237-267. AASLD Practice Guideline - Chapman R et al. Hepatology 2010;51:660-678. Karlsen TH and Boberg KM. J Hepatol 2013;59:571-581. Lazaridis KN and LaRusso NF. N Engl J Med 2016;375:1161-1170. ESGE-EASL Clinical Guidelines. J Hepatol 2017;66:1265-1281. Primary Sclerosing Cholangitis Clinical Manifestations l Initially asymptomatic (AP, γ-gt ) l Pruritus, pain, fatigue, jaundice l Complications: - bacterial cholangitis - cholangiocarcinoma (1.5% per year) - complications of chronic cholestasis - complications of cirrhosis - colorectal cancer Primary Sclerosing Cholangitis Diagnosis l Alkaline phosphatase, γ-gt l MRCP l "Atypical" panca pos. in 50-80% but not sufficiently specific l Evtl. ERCP (antibiotic prophylaxis!) l Evtl. liver biopsy (staging) l Colonoscopy Courtesy of Prof. Laura Rubbia-Brandt 4
Primary Sclerosing Cholangitis Management PSC DD PSC-PBC PBC l Ursodeoxycholic acid 13-15 mg/kg/d (?) l Endoscopic dilation of dominant stenoses l Treatment of pruritus l Prevention / therapy of osteoporosis l CCA and CRC surveillance l Liver transplantation - Medium and large BD - > - ~ 40 years - Association with IBD - MRCP - Recurrent bacterial cholangitis - Cholangiocarcinoma - UDCA 13-15 mg/kg/d? - Small bile ducts - > - 40-60 years - No association with IBD - AMA (M2) - Progressive cholestasis, pruritus - No cholangiocarcinoma - UDCA 13-15 mg/kg/d Overlap Syndromes l Primary biliary cholangitis Boberg KM et al. on behalf of the IAIHG. J Hepatol 2011;54:374-385. l Primary biliary cirrhosis IgG4-Associated Cholangitis l Steroid-responsive sclerosing cholangitis l >, median age ~ 60 years l Associated with autoimmune pancreatitis and diverse fibrosing conditions l Often presents with obstructive jaundice; no association with IBD and CCA l Serum IgG4 l IgG4-positive plasma cells l Corticosteroids, evtl. azathioprine Björnsson E et al. Hepatology 2007;45:1547-1554; EASL CPG. J Hepatol 2009;51:237-267; Stone JH et al. NEJM 2012;366:539-551. 5
Take Home Messages l Consider autoimmune liver disease in the differential diagnosis of elevated LFTs! ANA, AMA, SMA, IgG! MRCP l Regular follow-up and treatment adherence are crucial l Collaboration between GP and specialist l Progress in the understanding of the pathogenesis and management to be expected 10 th Challenges in Viral Hepatitis CHUV, January 18, 2018 Alessio Aghemo Hepatitis C Cristina Marcu and Andreas Cerny Tough hepatitis cases Charles M. Rice Hepatitis B Heiner Wedemeyer Hepatitis E www.gastro-hepato.ch 6